Bakgrund: Inom intensivvården vårdas akut och kritiskt sjuka patienter av  specialistsjuksköterskor inom intensivvård. Intensivvårdspatienter drabbas i stor utsträckning av delirium vilket är förknippat med ökad dödlighet och förlängd sjukhusvistelse. CAM-ICU är ett validerat bedömningsinstrument som identifierar om patienten drabbats av delirium. CAM-ICU beskrivs både som ett användarvänligt och ett svårhanterat bedömningsinstrument. Syfte: Syftet var att beskriva intensivvårdssjuksköterskors upplevelse av att använda bedömningsinstrumentet CAM- ICU hos intensivvårdspatienter. Metod: Kvalitativ intervjustudie med tio intensivvårdssjuksköterskor från ett sjukhus i mellersta Sverige. Analys av data enligt kvalitativ innehållsanalys. Resultat: I resultatet framkom tre kategorier: Att tillämpa bedömningsinstrumentet CAM-ICU, Bedömningsinstrumentet CAM-ICU användbarhet och Organisatoriska förutsättningar. Bedömningsinstrumentet CAM-ICU ledde till ökad medvetenhet om delirium hos intensivvårdssjuksköterskorna. CAM-ICU upplevdes registrera hypoaktiva delirium. Men användes i största del vid kliniska tecken på delirium. CAM-ICU flödesschema upplevdes enkel att följa men frågorna i instrumentet upplevdes ibland besvärliga att ställa. Stöd från ledning, påminnelser från kollegor och läkare upplevdes saknades efter identifierat delirium med CAM-ICU. Slutsats: Det ansågs vara ett trovärdigt verktyg som fångade upp hypoaktiva delirium. Upplevdes även som svåranvänd relaterat till frågorna i  bedömningsinstrumentet. Klinisk blick, teamarbetet, miljö och rutiner hade en viktig funktion för att intensivvårdspatienten ska få en bedömning med CAM-ICU. / Background: Within intensive care, acutely and critically ill patients will be taken  cared by intensive care nurses. Critically ill intensive care patients affected from intensive care delirium to a large extent and is associated with increased mortality and prolonged hospital stay. CAM-ICU is a validated instrument that assesses the mental state and whether the patient has delirium. CAM-ICU describes as a user friendly and difficult to handle. Purpose: Describe intensive care nurse's experiences of using the assessment instrument CAM-ICU in intensive care patients. Method: Qualitative interview study with ten intensive care nurses from a hospital in central Sweden. Analys of data according to qualitive content analyse. Results: Three categories were found in the results: To applicate assessment instrument CAM-ICU, the assessment instrument CAM-ICU ease of use and organizational conditions. CAM-ICU was found to register hypoactive delirium. But was mostly used for clinical signs of delirium. The CAM-ICU flowchart was perceived as easy to follow, but the questions in the instrument were sometimes perceived as difficult to ask. Support from management, reminders from colleagues and doctors were perceived to be lacking after delirium was identified with the CAM-ICU. Conclusion: It’s considered a good tool that captures hypoactive states of delirium. CAM-ICU where perceived as difficult to use in relation to the questions in the assessment instrument. The clinical view, teamwork, environment and routines had an important function for the intensive care patient to receive an assessment with CAM- ICU.

Due to advances in medical care, the number of patients surviving critical illness is on the rise. As a result, our healthcare system has a new and growing subset of patients dealing with a variety of issues related to survivorship. These issues, called post-intensive care syndrome, fall into three pillars: physical, cognitive, and psychiatric. While targeted efforts have begun to attempt to manage the physical and cognitive deficits, how to treat the psychiatric deficits remains unclear. So far, the handful of studies attempting to treat these psychiatric outcomes via a variety of approaches have had only limited success. Further, there is an inadequate understanding of the patient perception of these experiences and to better grasp this may help target future studies. The proposed study is a randomized, non-blinded, longitudinal controlled trial with the goal to limit the development of psychiatric symptoms following ICU admission. The intervention, conducted by a trained, Licensed Clinical Social Worker will take place in the form of a one time, in hospital debriefing of the ICU experience. Following the intervention, the patients will be surveyed to identify the presence of PTSD symptoms at various time intervals following hospital discharge. In addition, a number of interviews will be recorded and undergo qualitative analysis to identify cohesive themes and develop a better understanding of the patient perception of their experience. If successful, this study would lead to an improved quality of life for this patient population, as well as lessen their dependence on the healthcare system, reducing the associated financial burden following ICU admission.

Acute Respiratory Distress Syndrome (ARDS) is associated with lung inflammation and fluid filling, resulting in a stiffer lung with reduced intrapulmonary gas volume. ARDS patients are admitted to the Intensive Care Unit (ICU) and require Mechanical Ventilation (MV) for breathing support. Positive End Expiratory Pressure (PEEP) is applied to aid recovery by improving gas exchange and maintaining recruited lung volume. However, high PEEP risks further lung injury due to overstretching of healthy lung units, and low PEEP risks further lung injury due to the repetitive opening and closing of lung units. Thus, selecting PEEP is a balance between avoiding over-stretching and repetitive opening of alveoli. Furthermore, specific protocols to determine optimal PEEP do not currently exist, resulting in variable PEEP selection. Thus, ensuring an optimal PEEP would have significant impact on patient mortality, and the cost and duration of MV therapy. Two important metrics that can be used to aid MV therapy are the elastance of the lungs as a function of PEEP, and the quantity of recruited lung volume as a function of PEEP. This thesis describes several models and model-based methods that can be used to select optimal PEEP in the ICU. Firstly, a single compartment lung model is investigated for its ability to capture the respiratory mechanics of a mechanically ventilated ARDS patient. This model is then expanded upon, leading to a novel method of mapping and visualising dynamic respiratory system elastance. Considering how elastance changes, both within a breath and throughout the course of care, provides a new clinical perspective. Next, a model using only the expiratory portion of the breathing cycle is developed and presented, providing an alternative means to track changes in disease state throughout MV therapy. Finally, four model-based methods are compared based on their capability of estimating the quantity of recruited lung volume due to PEEP. The models and model-based methods described in this thesis enable rapid parameter identification from readily available clinical data, providing a means of tracking lung condition and selecting optimal patient-specific PEEP. Each model is validated using data from clinical ICU patients and/or experimental ARDS animal models.

Background: Intensive care unit (ICU) admission is often life threatening, and may cause severe anxiety within the family system. Anxiety can impair decision-making ability. A majority of ICU patients cannot direct their own treatment; therefore, family members are often required to make major decisions under stressful conditions. Patient and family-centered care (PCFF) has been shown to reduce anxiety, improve decision-making, and improve outcomes for patients and their families. However, no published study has examined outcomes of a comprehensive PFCC program in the ICU. Purpose: The study purposes were to evaluate a comprehensive program to improve PFCC within an adult ICU, and to determine the usefulness of specific PFCC interventions. Methods: An exploratory comparative design was used. Data from ICU patients' family members and ICU nurses, before and after implementation of a PFCC program, were compared using the 30-item combined Critical Care Family Needs Inventory/Needs Met Inventory (CCFNI/NMI). Convenience samples of 49 adult family members of patients admitted to the ICU for at least 36 hours and 85 nurses employed in the ICU full-time for at least six months were recruited from an adult ICU in a 337-bed tertiary care hospital in the southwestern region of the United States. The program was conducted in 3 stages: baseline assessment, program development and implementation, and evaluation. Results: After the PFCC implementation statistically significant differences between nurses' and family members' responses were reported for18 items on the CCFNI and 20 items on the NMI. Five of the10 items family members ranked highest at baseline remained in the top 10 after PFCC implementation, and 3 needs ranked lowest at baseline moved up to the top 10. Conclusions: The results show that the nurses' education was likely the most efficacious program intervention. There may be a hierarchy of needs specific to ICU patients' family members, similar to those described by Maslow. Further study is needed to determine the effectiveness of the CCFNI/NIM in measuring outcomes before and after a PFCC intervention.

Bakgrund: Minnen från intensivvård är ett ämne som är väl undersökt. Det är sedan tidigare känt att de minnen och upplevelser patienten har från intensiwårdstiden kan leda till ppykologiska problem som påverkar patienten en lång tid efter utskrivning. I flera studier i ämnet har neurokirurgiska patienter exkluderats. Syfte: Syftet med denna studie var att beskriva neurokirurgiska patienters minnen och upplevelser av intensiwårdstiden. Metod: Datainsamlingen skedde genom semistrukturerade intervjuer utifrån ICU Memory Tool. Totalt intervjuades fyra patienter. Materialet har dels sammanställts kvantitativt dels analyserats utifrån kvalitativ innehållsanalys. Resultat: De minnen och upplevelser patientema hade från intensiwårdstiden resulterade i tre övergrþande teman, Att vara i en drömvtirld, Att vara i en luinslomdssig vdrld samt En verklig vrirld. lnom varje tema återfanns såväl negativa som positiva minnen och upplevelser.

Purpose: To introduce the simplified therapeutic intervention scoring system (TISS-28), the original therapeutic intervention scoring system (TISS-76) and simplified acute physiological score (SAPS) version II in critically ill adult patients, in order to describe the validity and reliability of TISS-28 as a suitable measure of quantifying nursing workload in the adult intensive care units (ICU) of a public sector hospital in Johannesburg. Objectives: To describe the profile of patient admissions to the intensive care units, to investigate the impact of the patients’ profile on the requirements for nursing workload and to validate the use of TISS-28 as a measure of quantifying nursing workload in this setting. Design: A non-experimental, comparative descriptive, correlational and prospective two-staged design was utilized to meet the study objectives. Stage I involved face and content validation of TISS-28 by a panel of ICU nurse experts (n=6). Stage II involved assessment of concurrent and construct validity as well as inter-rater reliability of TISS-28 using participants (n=105) drawn from trauma, cardiothoracic and multidisciplinary ICUs. Data necessary for the calculation of TISS-28, TISS-76 and SAPS II were recorded for each patient in the ICU at 24 and 48 hours after admission and in the wards after discharge within 24-48 hours. Descriptive and inferential statistics were used to analyze data. Results: Content Validity Index (CVI) of 0.93 was found for TISS-28. A significant positive correlation was found between TISS-28 and TISS-76 scores (r = 0.7857, p = 0.0001) as well as TISS-28 and SAPS II scores (r = 0.2098, p = 0.0317). A significant difference was found between TISS-28 scores among patients in the ICU and patients in the ward (t = 25.59, p = 0.0001; t = 21.48, p = 0.0001) respectively. A significant correlation was found between the data collected from a sample of patients by the researcher and the expert assistant researcher with an intra-class correlation coefficient of 0.99 and a p-value of 0.0001. Conclusions: The findings support validity and reliability of TISS-28 hence its feasibility for use in South African ICUs. Recommendations for nursing education, practice, management and research are proposed.

Conselho Nacional de Desenvolvimento CientÃfico e TecnolÃgico / A infecÃÃo hospitalar à atualmente a mais freqÃente e importante causa de Ãbito de pacientes internados em unidades de terapia intensiva pediÃtrica. Para conhecer a dimensÃo desse problema em um Hospital PediÃtrico que possui um atendimento terciÃrio localizado no CearÃ, foi realizado um estudo de coorte prospectivo de todas as crianÃas internadas na UTIP no perÃodo de 01 de agosto de 2007 a 31 de janeiro de 2008. Uma coorte de 66 pacientes foi seguida da internaÃÃo a alta ou Ãbito. Ao todo 18 variÃveis do paciente e hospitalares foram pesquisadas em cada membro da coorte. Os testes estatÃsticos utilizados foram: Mann-Whitney e o teste exato de FISCHERâS, o cÃlculo do risco relativo com os respectivos intervalos de confianÃa. Em seguida procedeu-se a anÃlise multivariada com transformaÃÃo para regressÃo logÃstica dos fatores mais significativos (p<0,05). Ao final, um fator foi selecionado como preditor independente da infecÃÃo hospitalar: intubaÃÃo orotraqueal (OR=2,29, IC95%=1,38 a 3,82). A incidÃncia de infecÃÃo hospitalar foi de 54,6% (35IH/64pacientes). As bactÃrias mais prevalentes dos casos confirmados foram os bacilos gram-negativos (73,3%). A internaÃÃo dos pacientes com infecÃÃo hospitalar foi de 2,9 vezes superior a internaÃÃo dos pacientes nÃo acometido. A probabilidade de Ãbito global esperado foi de 13% e a observada foi de 43,9%. Este estudo poderà ser Ãtil para futuras estratÃgias com vistas a diminuir a morbimortalidade por infecÃÃo hospitalar.

The purpose of this study was to identify Canadian critical care nurses’ attitudes about the importance of families in nursing care in adult intensive care units (ICUs), explore their perceptions of family-centered care (FCC), and examine policies and practices in place that promote FCC in adult ICUs. A web-based survey was used with a sample of members (N = 207) of the Canadian Association of Critical Care Nurses. Using the Families Importance in Nursing Care: Nurses’ Attitudes (FINC-NA) instrument, it was found that age and years of ICU experience were positively related to more positive attitudes (n = 193), while direct care providers had lower scores than nurses in other roles. Nurses identified benefits for patients, families, and staff associated with FCC, but also outlined challenges in implementing FCC, including comfort of nurses and a lack of support from team members. Nurses’ responses to questions about FCC policies and practices illustrated concerns with the implementation of FCC in the units the nurses worked in. The results of this study have implications for practice, education, and research.

Bakgrunn: Blodbaneinfeksjon er en av de alvorligste sykehusinfeksjonene pasienter kan utsettes for, og i intensivavdelingen rammes de mest sårbare pasientene. Målet med studien:Å finne insidensen av blodbaneinfeksjoner (BSI) i en intensivavdeling i et lokalsykehus i Norge, samt undersøke ulike risikofaktorer knyttet til Centrale Venekatetre (CVK) og generell infeksjon ved innleggelse i intensivavdelingen. Metode: Insidensregistrering av BSI i løpet av 12 mnd. der definisjoner av BSI bygger på 2001 International Sepsis Definition Conference. Data er samlet inn prospektivt etter hvert som pasientene ble lagt. Studiepopulasjonen er antallet pasienter som hadde vært innlagt i mer enn 48 timer i intensivavdelingen, og deles opp i tre åpne kohorter:Pasienter med diagnostisert BSI i løpet av oppholdet, pasienter som fikk lagt inn CVK og pasienter med infeksjon ved innleggelse. Resultater: 615 pasienter ble lagt inn i intensivavdelingen i løpet av 12 mnd, av disse ble 116 av de pasientene som hadde vært innlagt i intensivavdelingen i mer enn 48 timer inkludert i studien. Gjennomsnittlig liggetid i intensivavdelingen varierte fra 2 til 40 (median 4 dager). 73 av de 116 pasientene fikk lagt inn CVK, og av disse fikk 11 en bekreftet BSI. Tre pasienter uten CVK fikk bekreftet BSI, totalt 14. Av disse 14 var 6 nosokomiale, altså 5,2 % (6 av 116) eller 7,8 BSI/1000 pasientdøgn. Enpasient fikk diagnosen kateter-relatert BSI(CR-BSI), noe som tilsvarer 1,7 CR-BSI/1000 kateterdøgn. Det ble tatt totalt 69 blodkulturer, herav 54 fra pasienter med CVK. Pasienter med CVK har signifikant større risiko for å utvikle klinisk BSI, enn de utenCVK (OR=5,31; 95 % CI 2,32 –12,0; p&lt; 0,0001). Konklusjon: Denne studien viser en relativt lav forekomsten av BSI, NBSI og CR-BSI, men for å kunne sammenligne tall nasjonalt og internasjonalt er det behov for en consensus i fagmiljøet rundt definisjoner BSI og særlig CR-BSI. Det er signifikant sammenheng mellom CVK og utvikling av klinisk BSI, men studien viser ingen signifikant sammenheng mellom CVK og bekreftet BSI. Studien bør bidra til fokus på risikofaktorene knyttet til bruk av CVK, samt arbeid for consensus angående definisjoner og økt fokus på CR-BSI og klinisk BSI, siden dette har vist seg å ha like høy letalitet som bekreftet BSI / Background: BSIs is areof the most serious hospital infections patients are exposed to, and in the intensive care unit (ICU) it affects the most vulnerable patients. Aim: To find the incidence of BSI in an ICU in a local hospital in Norway, as well as examine the various risk factors related to Central venous catheters (CVK), as well as patients with general infection at point of admission. Method: Incidence registration of BSIs within 12 months, where the definitions of BSI is based upon the 2001 Sepsis Definition Conference. Data is collected prospectively as patients were admitted to the ICU. The study population is the number of patients who had been hospitalized for more than 48 hours in the ICU, and the study population is divided into three open cohorts.Patients with diagnosed BSI during their stay, patients with CVK during stay and patients with infection at admission. Results: 615 patients were in the ICU within 12 months, and 116 of those patients had been hospitalized for more than 48 hours in the ICU and were included in the study. Average length of stay ranged from 2 to 40 days (median 4 days). 73 of the 116 patients had CVK in place during their stay, andof these 11 had a laboratory confirmed BSI. Three patients without any central CVK in place during their stay in the ICU had a laboratory confirmed BSI, 14 in total. Of these 14, 6 weredefined nosocomial, i.e.5.2% (6 of 116) or 7.8 BSI/1,000 patient days. One patient was diagnosed with catheter-related BSI (CR-BSI), which corresponds to 1.7 CR-BSI/1, 000 catheter days. A total of 69 blood cultures were performed, of which 54 patients with CVK. Patients with CVK has a significantly higher risk of developing clinical BSI than those without CVK (OR = 5.3, 95% CI 2.32 to 12.0, p &lt; 0.0001). Conclusion: This study shows a relatively low incidence of BSI, NBSI and CR-BSI. CVK is significantly related to the development of clinical BSI, but the study shows no link between CVK and laboratory confirmed BSI. This study may encourage health care  workers to focus more on the risk factors associated with the use of CVK to critically ill patients. It should also encourage researchers to focus more on the importance of consensus regarding definitions of BSI and clinical BSI, since this have been proven to have as high lethality rates as laboratory confirmed BSI / <p>ISBN 978-91-86739-86-7</p>

SAMMANFATTNING Bakgrund: Risken för att drabbas av ett intensivvårds-delirium under vårdtiden är av varierande storlek. Om patienten drabbas av ett delirium kan det leda till allvarliga konsekvenser. Konsekvenserna innefattar en ökad mortalitet, längre vårdtid, ett ökat lidande och även att kostnaderna blir högre. De bedömningsinstrument som finns används i varierande grad på olika intensivvårds-avdelningar världen över. Det mest valida och användbara är Confusion Assesment Method, CAM-ICU; ett mätverktyg utarbetat för att användas inom intensivvården där det kan användas på patienter som fortfarande är intuberade och således inte har en möjlighet att uttrycka sig verbalt. Syfte: Belysa den aktuella forskningen gällande omvårdnad av patienter som drabbats av intensivvårds-delirium. Metod: Studien är en litteraturöversikt med mixad metod och konvergent design. Resultat: Studien visar att omvårdnadsåtgärder gällande behandling av intensivvårdsdelirium används men det finns inga riktlinjer för hur patienterna ska behandlas. Den forskning som finns visar få signifikanta resultat. De kategorier av omvårdnadsåtgärder som litteraturen visar är kognitiv stimulans, miljö, läkemedelsanvändning och fysisk fasthållning. Slutsats: Studien visar att det är svårt att mäta effekterna av olika omvårdnadsåtgärder som patienter med intensivvårds-delirium blir behandlade med. Klinisk betydelse: Genom fördjupad kunskap om delirium får sjuksköterskan en bättre förståelse för tillståndet och således även för omvårdnaden som ges. Att belysa det faktum att forskningen kring omvårdnadsåtgärderna vid delirium är bristfällig skapas möjlighet till vidare efterforskning. / ABSTRACT Background: The risk for intensive care delirium during hospitalization is of varying size. If the patient experiences a delirium it can lead to serious consequences. The consequences include increased mortality, longer hospital stay, increased suffering and even higher costs. The screening tools that are available are used in varying degrees in different intensive care units worldwide. The most valid one are the Confusion Assessment Method, the CAM-ICU; a screening tool developed for use in intensive care where it can be used on patients who are still intubated and thus do not have a chance to express themselves verbally. Aim: Highlighting the current research regarding the care of patients suffering from intensive care delirium. Method: The study is a literature review with a mixed approach and convergent design. Results: The study shows that nursing interventions regarding the treatment of intensive care delirium are used but there are no guidelines for how the patients should be treated. The research shows few significant results. The categories found from the literature were cognitive stimulation, environment, medication and physical restraint. Conclusion: The study shows that it is difficult to measure the impact of nursing interventions that patients with intensive care delirium are treated with. Relevance to clinical practice: Increased knowledge of delirium may give the nurse a better understanding of the condition and thus also for the care they provide. To highlight the fact that the research on nursing interventions for delirium is flawed which creates the opportunity for further research.